The Intoxicating Appeal Of Waste and Dysfunction: Healthcare Through The Eyes Of An Entrepreneur

Monday’s WSJ includes my review (link; PDF) of Where Does It Hurt?,athenahealthathenahealth CEO Jonathan Bush’s account of how the company was built, and more generally, how entrepreneurs might – and must — impact healthcare.

The review speaks for itself, but (following the inspired example of Christopher Chabris), I wanted to share some additional color.

While the deficiencies of our current healthcare system have been widely discussed and exhaustively lamented, it’s refreshing and instructive to see how these challenges look through the eyes of a seasoned entrepreneur. And as Bush writes, “From an entrepreneur’s point of view, there’s something highly appealing, almost intoxicating, about waste and dysfunction in the industry.”

A stint as an army medic (he trained but never saw combat) showed Bush that with practice and discipline, “ordinary people” without extensive education could be taught to performing complex tasks, such as operating multi-million dollar missiles or performing battlefield tracheotomies” – a perspective that led him and Todd Park (now Obama’s Chief Technology Officer) to launch Athena Women’s Health, the midwife-driven obstetrics startup that ultimately became today’s athenahealth. (See the review for details on this interesting evolution, and Atul Gawande’s first New Yorker piece, here, for an example of “training up” medical skills in practice, in the context of hernia repairs at the Shouldice Hospital in Canada.)

Where Does It Hurt? is a fast-paced, engaging narrative (steadied by experienced business writer and co-author Stephen Baker) that faithfully captures the manic energy and rapidly cascading thoughts so evident in Bush’s popular conference presentations and widely-viewed 2013 TEDMED talk, “What’s Wrong With Profit In Healthcare?”

Fundamentally, Bush believes that the marketplace, for lack of a better word, is good. “The marketplace works,” he explains. “It rewards innovators, kills laggards, and provides consumers with better value and more choices…Only markets have the force and tenacity to drive the innovation and efficiency we need.”

While the “corduroy-elbow crowd in research hospitals and foundations” may view profits as “a dirty work,” Bush says, profits are the fuel for growth and innovation (a view closely aligned with that of Whole Foods MarketWhole Foods Market CEO John Mackey – see here.)

What distinguishes Bush from many Silicon Valley technology titans who’ve now taken their talents to healthcare (see here), and perhaps why he’s been more successful there than most (an assertion with which Greenlight Capital’s David Einhorn might emphatically disagree), is that he wants to disrupt medicine without repealing and replacing it.

“the deep one-on-one relationship between two people, the doctor and the patient…is what is unique in health care. During these encounters, the doctor focuses on one fellow human being, with the goal of figuring out what ails this person and how to fix or alleviate it. It is this act of total presence – I would go so far as to call it a form of love, that should exist at the heart of health care.”

The key to achieving this, says Bush, is essentially for doctors and hospitals to practice at the top of their licenses – to focus on what they can uniquely offer — and allow other providers and clinics deliver care that is more routine.

Let entrepreneurs loose on these challenges, Bush says, and they’ll develop solutions that enable medicine to become not just faster and cheaper, but also better, for both patients and doctors.

Or at least for the doctors who are still employed. As Stanford health economist Victor Fuchs famously observed, “Every dollar of waste is income to some individual or organization” – many of whom, it turns out, are not welcoming change agents with open arms (as detailed in the review). Key obstacles Bush highlights include regulatory capture (see this recent discussion), especially by large hospital systems (a la Brill, and also this recent post by Paul Levy), as well as a culture that’s intrinsically conservative and resistant to change.

Perhaps Bush’s most significant contribution is not a specific proposal — some ideas resonate more than others (again, see review) — but rather, how effectively he communicates and exemplifies the power and potential of entrepreneurs to create, invent, and disrupt, in a fashion that transcends both politics and lineage. Startups are where a right-leaning Connecticut Yankee and a progressive son of Korean immigrants can come together, drawn by a shared sense of purpose and mission, and aspire to make a dent in the universe – and yes, pick up a few bucks along the way.

This is a good thing. To adapt a line from the 80’s entrepreneurial classic, Risky Business, healthcare can use more folks like Todd and Jon.

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